About the Book

• The Lady and the Unicorn: A Psychological Metaphor



• Dreaming�With Eyes Wide Open: Schizophrenic Hallucinations



• Information Processing in Schizophrenia



• Clarification of our Clinical versus Forensic Function: Dual Relationship



• Art Psychotherapy



• Lord of the Rings: A Psychological Metaphor



• Aviation Psychology



• So, You have just been Passed by a Girl! A Holley Carborator may help



• Approaches in Memory Rehabilitation



• Memory Enhancement Module



• Negaunee Center



• The Final Transition



• Is Deinstitution- alzation a Misnomer



• Token System: a Psychiatric Case Study



• A Token Economy System: Inpatient Psychiatric Population



• Insight: An Aspect of Neurocognition

Negaunee Adult Day Treatment Center (NADTC) is a program for the dually diagnosed operated by the St. Clair County Community Mental Health Board. The program uses high structure to set up a predictable and consistent environment for clients. People are referred to NADTC primarily because of their severe behavioral problems such as aggression, self-abuse, and property damage. The program focuses on six areas summarized by the acronym ACCESS, which denotes �Assessment, Communication, Community, Education, Simulated work and Socialization.� The basic treatment approach used is a token system which clients are introduced to upon entering. Tokens are presented concurrently with social reinforcement. NADTC accepts clients with an understanding of eventually referring them to less restrictive work or day programs.

The NADTC is a program operated by the St. Clair County Community Mental Health Services Board. NADTC was specifically designed to provide a highly structured environment, which would expose clients to community resources and activities. The goals of this program, for dually diagnosed clients are to improve socio-interactive behaviors and to develop daily living skills necessary for community placement. Individuals qualified for the program are those clients who have been identified as handicapped in both intellectual and emotional functioning areas.

�A dually diagnosed client is an individual who functions at any level of mental retardation and simultaneously exhibits symptoms reflecting a psychiatric disturbance that requires treatment attention (Tsegae-Spates and DePriest, 1986).� Additionally, those individuals served at NADTC typically displayed severe maladaptive behavioral problems, which resulted in the need for highly structured programming. Some of the general classes of maladaptive behaviors are aggression, self-abuse and destruction of property.�

Behavioral learning theory and practice have demonstrated that a highly structured environment facilitates learning, of the developmentally disabled as well as the mentally ill client. The structure of a predictable and consistent environment facilitates learning with minimal amounts of stress and distracting stimulation. Thus, the individual can concentrate on the learning process instead of being wrapped up in internal feelings of anxiety or external distractions. �When a client is behaving in a self-defeating manner and there are no immediate and potent reinforcers in the natural environment for behaving otherwise, a self-control regimen might well be the most feasible treatment (Rimm and Masters, 1979).�

At times clients can feel confused and respond to imaginary conditions or stimuli. That can be overwhelming as clients' covert verbal behavior and inaccurate responses to external variables interfere with their concentration on an assigned task. To prevent such interferences with learning one must provide a highly structured environment with clearly defined expectations as well as provide the needed feedback to clients.

Persons referred to NADTC displayed severely maladaptive behaviors, which prevented them from successfully adapting in a more traditional vocational or skill development program. Such behavioral problems had been generally described in terms such as poor impulse control, short attention span, or a low threshold for frustration. They also had been described in terms of physical aggressiveness, self-abuse, and property damage. An example of such problem behavior was seen in a person who was unable to perform a requested task and hit himself or a peer to avoid the task. Hitting with one's fist is a preferable, more specific way of defining target behaviors.

Besides overall limited intellectual functioning, many clients were physically handicapped or suffered from seizure disorders or organic brain damage/injury. Some of the common sources of the organic brain damage/injury were prenatal trauma, chromosomal abnormalities, or parental ingestion of toxic substances. As a result many of the clients exhibited limitations in development and needed to learn basic skills such as toileting, rudimentary communication, and self-feeding skills. Regardless of the nature of the physical disability, clients were referred to NADTC primarily because they had demonstrated some type of serious maladaptive behavior.

Clients referred to NADTC were residents of Sr. Clair County who could not be effectively managed in a less restrictive setting. The majority of clients who attended the program exited directly from state institutions although appropriate referrals were received from the community. Participants in the program ranged from 18 to 55 years of age. Many of the clients resided in mental health group homes or foster care facilities.

1. Assessment: All clients received a thorough medical, psychological, and social assessment. The assessments included an evaluation of the extent and nature of the client's organic complications. a psychological profile that addressed the behavioral variables which interfered with adaptive functioning, and a sociological assessment which prioritized goals and investigated environmental influences that may have played a role in the individual's ability to cope with the outside world. Additionally a monthly medical and medication review were updated on a regular basis.


2. Communication: Without some type of communication skills it is difficult to elicit attention or gain satisfaction from the environment. Therefore the development of client communication skills was a high priority. These skills helped the client express desires and feelings. Training included the use of picture boards, photographs, sign language, blissymbols, computers, as well as verbal and gestural _expression.


3. Community: Activities were provided to encourage development and improvement of adaptive skills considered helpful for clients to live in the community. These skills included many areas of the client's lives such as personal hygiene, cooking, nutrition, money management, home maintenance, shopping, physical exercise and leisure time activities. Education: More advanced learning skills were provided, such as expanding vocabulary, perceptual motor training, survival signs, basic writing, mathematic and reading skills. In some cases, if a person had not finished their formal education, credit toward a diploma or General Educational Development (GED) was obtained.


4. Simulated work: Appropriate vocational behavior and pre-vocational skills were targeted for improvement since their mastery would increase client's chances in the community. Simulated work training was an important part of pre-vocational and vocational skills development. While immediate reinforcement for work accomplished was provided it was discovered that the incentive of eventually being placed at a work activity, sheltered workshop or a supportive employment

Site also was of interest to some clients.

5. Socialization: Learning appropriate use of group leisure time, and developing social interpersonal skills were stressed. These skills were taught and maintained by staff and clients modeling desired behaviors to less skillful clients. The literature suggests that "Almost any learning outcome that results from direct experience can also come about on a vicarious basis through observation of other people's behavior and its consequences for them. Indeed, providing an appropriate 'modeling' may accelerate the learning process, and one method of social-learning therapy is therefore based on modeling the desired behavior" (Bandura, 1967).

A token economy system was used with each client in a program service areas. "A token reinforcer is an object with redeemable value, one that can be traded for an actual reinforcer of another kind (material, social. or activity... )" (Rimm and Masters, 1979. p. 173). Ayllon and Azrin, (1968), Schaefer and Martin, (1969), Thompson and Grabowski, (1972 and 1977), and Baker and Goncalves (1987) have demonstrated the usefulness of a token economy in working with the developmentally disabled. "The use of easily managed tokens also removes the necessity for the contingent dispensation of bulky, messy, or otherwise unmanageable reinforcing events. Perhaps the primary advantage, however is the ability, by manipulating the rate of exchange, to allow individuals to work over extended periods of time for a single, highly potent reinforcer. At the same time. the staff is able to dispense tangible reinforcement (if conditioned) after each response with short temporal delays. Both of these factors serve to increase the effectiveness of the reinforcer� (Rimm and Masters, 1979, p 191).

Upon referral of a client to NADTC an initial assessment and service plan is developed. After an additional period of one or two weeks evaluation and base lining. the initial service plan and treatment goals could be modified or expanded to meet the individual's needs. "After all, the purpose of the baseline period is to establish how often the behavior is occurring. The baseline period ends when you have some confidence that you understand the actual patterns of your behavior frequencies ", Our rule of thumb is: If the behavior is daily, always gather the baseline for at least one week" (Watson and Tharp, 1972, pp. 96-7).

However, new clients began immediately receiving tokens for program activities. In any behavioral plan, having the client achieve success immediately is the crux for continued motivation to achieve the next objective.' Tokens were awarded for 1) attendance, 2) staying and 3) participating in a group session. "Attendance" was defined as entering the group area at the proper time with or without minimal verbal prompts; "staying" was defined as remaining in the group area without leaving during all non break times; �participating� was defined as joining or performing the planned activity.

Additional tokens could be earned at a predetermined rate by engaging in appropriate behavior or accomplishing certain tasks. For example, offering to sweep the floor, cleaning an area up, completing extra math problems were reinforced with additional tokens. Verbal/social reinforcement was always paired with the token presentation with the intent of gradually replacing the token system. There are typically five separate sessions in the client's day. Therefore clients could earn enough immediately to purchase edibles, special privileges or additional desired items. Purchases were made at a token store where items such as a pen and pencil set cost 100 tokens, gum or candy 25 tokens, pictures, 250 tokens, watches 150 tokens, etc.

Group activity sessions lasted fifty minutes with a ten minute break which also served as a token presentation time. Groups were run by two staff members. One staff was designated as "primary" and would present the material or facilitate the activities. The other "behavioral" staff recorded individual progress over time, task, behavior, prompts and success. This recording was very important in measuring the client's acquisition of new adaptive skills as well as progress on numerous goal areas. This second staff member could also individually handle specific behavioral problems which arose during the session.

Problem behaviors were dealt with in a hierarchy of interventions. The first level was defined as redirection. This level included verbal, gesture or gentle physical guidance. The second level was ten token reminders. At this level clients were informed that desired behavior resulted in receiving tokens, while undesired behavior resulted in token loss. The third level, if needed, resulted in the clients being required to leave the reinforcement area until the time they felt ready to re-enter and resume the group activity. Feeling ready was defined in tens of actually displaying desirable behaviors and/or verbalizing intent to behave well.

Clients who resided in group homes had an additional system in conjunction with the NADTC program. They received tokens (punched) on their daily card for appropriate or desired behaviors at the same time tokens were issued at NADTC. The clients could later receive reinforces at home as well as at NADTC based upon their desirable behaviors. This consistency between the group home and the day program was an important key to the success of teaching adaptive behaviors as well as decreasing the probability of behavior problems. Additionally, tokens could be lost (response cost) for inappropriate behavior.

An example of how tokens could be earned and token response cost is listed below:

In a five year period (October 1. 1981-0ctober 31. 1986) LADTC received fifty referrals to the program; during that time period twenty-nine referrals were made out of the program. Twenty-four of the twenty-nine were referred to less restrictive program settings. The referral sites included other day treatment programs, work centers of Goodwill and the Association for Retarded Citizens. and various skill development centers.

Five referrals were made to the more restrictive of the state regional center hospital. The need for hospitalization was based on behavior problems that took place at a higher frequency or greater intensity than could be effectively managed. One client frequently and severely hit others. One damaged property by setting rules. One chronically bolted from program premises. Two physically struck out at others as well as engaged in frequent property damage.

Gradually, as progress was made, the reinforcement schedule was altered by decreasing the frequency and/or number of tokens. Social reinforcement was paired with tokens with the intent of eventually being able to maintain the desirable behaviors relying solely upon social reinforcement. As the clients gained skills, mastered problem solving techniques, and became less dependent upon tokens, they were referred to less restrictive work settings and day programs.

The NADTC program is a working example of how severely disabled dually diagnosed clients can be programmed in community settings. This program can be replicated with Minimum effort.

REFERENCES